Letter to ACOG on Home Birth

Stuart J. Fischbein's Letter to ACOG, with responses
Fri, 06/27/2008 - 07:03 — admin
Stuart J. Fischbein, MD FACOG
Douglas H. Kirkpatrick, MD, President, American College of Obstetricians and Gynecologists
Date sent:
Monday, June 23, 2008
Douglas H. Kirkpatrick, MDThe American College of Obstetricians and GynecologistsPO Box 96920Washington, DC 20090-2188Dear Sir:I am a practicing OB/GYN in southern California and Fellow of ACOG and recently was informed by midwife colleagues of your recommendation and encouragement for the AMA to lobby Congress for a law banning out of hospital birth. It is disturbing to me that I had to hear of this decision from outside sources and was never approached by my college to see how I or my local colleagues felt about it. I have grave concerns regarding my organization taking such a stand. I think we are all agreed that ACOG has a statement regarding patients’ rights to informed consent and informed refusal. Yet, it seems with every decision our organization moves further away from that basic tenet. ACOG’s little "guideline" paper on VBAC in 2004 where the word readily was changed to immediately has had the chilling effect of doing away with VBAC options at hundreds of hospitals. Not due to patient safety, or the ideal of giving true informed consent but really, let’s be honest, due to fear of litigation. I have seen how patients have become counseled by obstetricians at facilities where VBAC has been banned. They are clearly given a skewed view of the risks of VBAC but rarely told of the risks of multiple surgeries. If you think this is untrue you are, sadly, out of touch with real clinical medicine.As to out of hospital birthing, please give me the courtesy of an explanation as to the evidenced-based data you used and the process by which an organization which is supposed to represent me came to this conclusion. Any statement saying that it is as simple as patient safety and that one-size fits all hospital births under the "obstetric model" of practice should be applied to all patients is, putting it nicely, not really in line with what best serves all our patients. In many instances, hospitals are not safe, certainly not nurturing and have a far worse track record for disasters than home birth. Even when emergency help is nearby this is true. The focus of all of us in medicine should be on reigning in trial lawyers and tort reform and lobbying Congress for that. The best interest of the college members and the patients we serve would be for my organization to spend its time and energy on something that has true benefit. Removing choices from well-informed patients and caring doctors and midwives is wholly un-American. So please send me detailed information on how ACOG decided outlawing home birth would be a wise thing to do. You must have conclusive scientific data to take such a drastic stand. Please make it available to me so that I may share it with likeminded colleagues. I would also like to know the process by which this came to pass. Who first raised this issue and why? What committee reviewed all the data and did its due diligence in interviewing those of us with longstanding experience in backing midwives who perform out of hospital births. There must be a clear and concise, non-confidential paper trail you can share with your members. Specific names of committee members who voted for this would be enlightening and I am requesting this information. I would like to know the background and expertise regarding out of hospital birth for each member who had a hand in the decision to go to the AMA.We live in an odd era where once something is said or recommended by a legitimate organization such as ACOG it has deep ramifications never intended such as becoming fodder for trial lawyers trying to squeeze the lifeblood and dignity out of your members. In this case these ramifications have had the undesirable effect of forcing women to travel hundreds of miles in labor to find a supportive facility. Or even worse, to have them arrive in a VBAC banned hospital and refuse surgery or be coerced into it. Can this be the best we can do for our patients? Remember, your VBAC statement was meant to be only a recommendation but quickly became the rule by which hospital administrators, risk managers and anesthesia departments of smaller hospital banned this option for thousands of women. An option, which in proper hands, was the safe and accepted standard of care for 30 years. In fact, you still have an ACOG VBAC brochure that recommends this option! For those of us working at smaller hospitals where VBAC was banned due to lack of emergency help (anesthesia, OR crews, etc.) there is a big question that has perplexed us that no administrator seems to be willing or able to answer. That question is: "If a hospital cannot handle an emergency c/section for VBACs, and most obstetrical emergencies are for fetal bradycardia, hemorrhage (i.e. abruption) or shoulder dystocia not for ruptured uteri, then how can they do obstetrics at all?" For they seem to still be able to have a maternity ward without in house anesthesia. Will someday ACOG, in their great wisdom but seeming disconnect from reality, make a "recommendation" that little hospitals unable to afford 24-hour coverage stop providing obstetric services all together? Will this better serve women and their communities throughout America? I am frightened and angered by what you have done in my name. Now I ask you to defend your position in encouraging the AMA to lobby Congress for another restriction on the freedom of choice that belongs to women and their families. Those choices include midwifery and the right to have the most beautiful and life changing event occur wherever best fits their desire. I am baffled that my college thinks this should be a criminal act. Midwives are well trained and required to have obstetrical backup. They have very special relationships with their patients and want the very best outcomes for them. They do not need me or you to police them. We have a habit in out country over the past 40 years of thinking we can legislate out stupidity. All that has done is erode the individual freedoms that belong, by birthright, to each of us. I would hope you trust your Fellows to know their specialty, their colleagues, and what is best for the patient as an individual. These decisions do not belong to politicians or faceless committees. You should have more faith in your members to give balanced informed consent. Again, my recommendation to you is to put all your considerable energy into changing our legal malpractice system. Those of us actually practicing medicine and caring for patients know this to be the greatest threat to the mission and responsibility we have chosen to undertake.I look forward to your response and possibly the beginning of a meaningful dialogue.
Sincerely,Stuart J. Fischbein, MD FACOGMedical Advisor, Birth Action Coalition

From: Ralph HaleTo: Stuart J. FischbeinSent: Tuesday, July 1, 2008 2:14:44 PMSubject: Home Births
We have received your email on Home births. The AMA statement is only a repeat of the ACOG statement that was sent to all Fellows in February of this year and is on our website. It is a slight revision of previous ACOG positions on Home births that was developed by a committee of ACOG, reviewed by a document review process involving college members and finally approved by our Executive Board. It is based on good evidence and patient safety concerns. I would correct the statement approves only hospital births. It also approves births in approved out of hospital facilities that have the ability to handle unforseen emergencies. We have received a few concerns, such as yours from our Fellows as well as some from the Media, however the vast majority of our members responding are in support. They include numerous reports of disasters that have resulted in fetal and maternal deaths related to home deliveries. The ACOG VBAC document is again an evidence-based document based on the fact that up to 2% of VBAC’s have a major complication that is life threatening and that, depending upon many factors, 20-40% of attempted VBAC’s fail to deliver. Again patient safety is the issue. ACOG still supports VBAC but only in a situation where immediate care of the complications if they occur can be handled. One of the problems with VBAC is that many hospitals and malpractice insurance carriers believe that any risk over 1 in 100 is too much for them to assume and thus they not ACOG restrict the practice. Thank you for communicating your concerns. I will share them with the practice division.
Ralph W. Hale, MD, FACOGExecutive Vice PresidentACOG409 12th Street, SWWashington, DC 20024-2188

Hello Dr. Hale,
I am so pleased to hear from you so promptly. Thank you. While I can understand ACOGs concerns regarding home birth and warnings about it, I and many of my colleagues have a significant concern that our college suggests making it illegal. America has always been the sort of country where the old saying, "Although I disagree with what you say, I would fight to the death for your right to say it!" defines the spirit of our people. In reading over many of the articles and such from the ACOG web site it seems that ACOG agrees with that saying and understands the right of a woman’s autonomy. I would appreciate your understanding that this current stand of ACOG against out of hospital birthing, even if supported by a majority, seems to defy those premises. I have highlighted some of the relevant articles on informed consent/refusal and autonomy below. I am glad you have acknowledged that in our current system policy is often dictated by third parties such as insurance companies. This resolution on home birth, even if never acted upon by the AMA or the legislature, will likely have the chilling effect of insurers dictating to doctors what they can and cannot do. This seems backwards to me and if midwives cannot find doctors willing and able to supervise them for out of hospital birth, not for their beliefs necessarily but for the "extortion" of loss of their malpractice insurance if they do, it will have the same effect of eliminating this choice for women without the necessity of a law. I do wish our organization’s top priority would be the complete overhaul of the tort/insurance dilemma that seems to be the biggest obstacle to a meaningful doctor-patient relationship. For the autonomy of our patients and the dignity of our profession lies in the balance. I am hopeful you will agree with my point here as well as the articles below and ask the practice division to reconsider its ACOG statement recommending a ban on home birth. Again, I am grateful you have taken the time to sincerely consider my letter.
Sincerely and with respect,
Stuart J. Fischbein, MD FACOG

PS: Is there a possibility you could share with me what "good evidence" was used by committee members. It would go a long way to helping convince those of us who do support a woman’s right to choose where she wants to give birth that the resolution was based on solid evidenced based decision making and those involved used due diligence. I would not ask if we believed the evidence is clear and convincing enough to take such a hard stance. Thanks

From: Ralph HaleTo: Stuart FischbeinSent: Wednesday, July 2, 2008 6:16:33 AMSubject: Re: Home Births

I agree that legislation would be bad. This was not the intent of the ACOG statement nor was it meant to prevent women who chose a home birth from having one. The AMA changes their resolutions by a consent process that involves testimony from reference committees and from the floor so once a resolution has been submitted and it was not submitted by ACOG but referenced our position, the changes were made. I doubt that this will ever be a legislative activity, I know ACOG has no interest in that approach. As regards changing the statement, that would require the committee on obstetrics that drafted it initially being willing to rescind and I doubt that would happen. If it did, then it would go to our review committee of senior physicians and finally the board. Knowing the feelings of both groups although I do not serve on either, I would doubt that they would agree. The emphasis on Patient Safety and the risks of home births are just too great for ACOG to think otherwise. I understand about home births as I have done several earlier in my career of pacific islands and I fully understand when the go right, they can be very rewarding. However when a complication arises, it is difficult and almost impossible to handle in a home situation. Here at ACOG we receive numerous reports from our Fellows on disasters that occur, including deaths, associated with home births that would not have happened in a safe birthing center environment. Last week I received an email from a Fellow who was called to the emergency room to manage a VBAC at home that had resulted in a ruptured uterus. The mother survived after an emergency hysterectomy, the baby did not. Anyway, I do appreciate hearing from you. I doubt home deliveries will stop, in fact they seem to be on the rise so we may be able in the future to have more information.

Ralph W. Hale, MD, FACOGExecutive Vice PresidentACOG409 12th Street, SWWashington, DC 20024-2188